Drugs Ther Perspect DOI 10.1007/s40267-016-0352-z ORIGINAL RESEARCH ARTICLE Consumption patterns of NSAIDs in central Portugal and the role of pharmacy professionals in promoting their rational use 1 1 1 Carina Monteiro • Cla´udia Miranda • Filipa Brito • 1,2 1,2 Cecı´lia Fonseca • Andre´ R. T. S. Araujo Ó Springer International Publishing Switzerland 2016 Abstract 6.3). Of the NSAID users, 47 % reported that they some- Background Non-steroidal anti-inflammatory drugs times, rarely or never received pharmacy professional (NSAIDs) are among the most widely used of all thera- recommendations. However, the majority (76 %) of peutic agents. In spite of their therapeutic efficacy, concern respondents said that they read medicine leaflets, and over the use of NSAIDs is largely related to their adverse considered NSAIDs to be effective and remarkably safe. effects in different organic systems, as well as their Conclusions Considering the main results of this study, it indiscriminate use. There is a lack of studies about the is imperative to promote the re-education of the population pattern of use of NSAIDs in Portugal. and improve the consultative role of the pharmacy pro- Objective The aim of this study was to characterize the fessionals regarding NSAID use. consumption pattern of NSAIDs by adult users in the central region of Portugal, as well as the role of the com- munity pharmacy professionals in counseling and pro- moting their rational use. Methods A questionnaire survey to determine sociode- Introduction mographic information and NSAID use characterization was administered to a sample of 450 pharmacy customers Non-steroidal anti-inflammatory drugs (NSAIDs) are fre- between October and November of 2013. quently used worldwide to treat a large number of common Results The prevalence of NSAID use was 57.6 % (95 % acute and chronic inflammatory conditions. These drugs CI 53–62). Most of the 259 NSAID users were aged possess different chemical and clinical profiles, but essen- 18–39 years (61.4 %), female (67.6 %), urban zone tially exert the same therapeutic properties and are associ- inhabitants (70.7 %) and practiced self-medication ated with similar adverse drug reactions (ADRs) [1–3]. (64.2 %). Self-medication with NSAIDs was significantly Besides gastrointestinal injuries (the most common ADR (p B 0.001) related to age, employment status and the use caused by this group) [4], there is evidence to link these of gastroprotective drugs. The concomitant use of NSAIDs agents to toxicities affecting the cardiovascular [5, 6]and and other medications revealed the possibility of drug renal [7] systems, as well as the liver [8]. Studies have interactions in people aged C65 years (prevalence ratio shown that both therapeutic and adverse effects of NSAIDs are dependent on cyclo-oxygenase (COX) inhibition [9]. Indeed, the COX enzyme can be divided into two isoforms: & Andre´ R. T. S. Araujo a constitutive and cytoprotective isoform (COX-1), which is [email protected] responsible for maintaining normal function in the gas- trointestinal and renal tracts; and an inducible isoform 1 ´ Polytechnic Institute of Guarda, Av. Dr. Francisco Sa (COX-2), which is found in inflamed tissues. Traditional Carneiro, 50, 6300-559 Guarda, Portugal 2 NSAIDs inhibit both isoforms, while specific COX-2 inhi- Research Unit for Inland Development (UDI), Polytechnic bitors have a substantially higher specificity for the COX-2 Institute of Guarda, Av. Dr. Francisco Sa´ Carneiro, 50, 6300-559 Guarda, Portugal isoform, thus preserving the anti-inflammatory property of COX-2 inhibition and reducing the ADRs related to inhi- community pharmacies in the Portuguese districts of bition to the COX-1 isoform, which results in a superior Aveiro, Castelo Branco, Guarda and Viseu between gastrointestinal and renal safety profile when compared with October and November of 2013. As this is an observational the non-selective COX inhibitors. However, COX-2 inhibi- study, based on the results of a survey, no formal approval tors increase the risk of serious cardiovascular events [7]. from any committee was required. In Portugal, according to the ‘‘Medicine and healthcare The target population included all adults aged[18 years products statistics 2014’’ compiled by the National who were residents of the Portuguese districts of Aveiro, Authority of Pharmacy and Medicines (INFARMED), Castelo Branco, Guarda and Viseu. According to the 2011 NSAIDs were the eighth highest pharmacotherapeutic Portuguese National Statistics Institute census, the base subgroup with regard to the number of packages sold [10]. population in these districts was 847,581. Based on this The statement is in line with another study, which showed population and a sampling error of 5 % plus 12.5 % to that NSAIDs placed fifth among chronically used medici- cover possible non-response, the estimated total sample nes and that they were used by 12–15 % of the study size was 450 (using the Taro Yamane equation). The participants [11]. Moreover, ADRs related to NSAID use, sample was stratified to reflect the proportional population especially gastrointestinal complications, continue to be of each district, resulting in 170 participants from Aveiro, reported to the Portuguese Drug Prescription Vigilance 76 from Castelo Branco, 75 from Guarda and 129 from System, representing 11 % of overall reports, and often Viseu. Respondents, aged[18 years and resident in one of causing hospitalization [12]. Similar results were obtained the four districts, participated voluntarily and anony- in France [1] and Spain [13]. mously, and were informed of the scope and objectives of Physicians have a key role in evaluating the need for the study. The survey of pharmacy customers was con- anti-inflammatory therapies, and if deemed necessary, in ducted by personal interview (mean duration 15 min), with selecting and prescribing the most suitable currently a single investigator recording the answers in a printed available NSAID, taking into account their tolerability questionnaire in order to avoid errors that could lead to profiles and possible negative influence on health. invalid answers. The researchers contacted all pharmacies According to the European Medicine Agency’s Committee in each district and obtained permission from a group of on Medicinal Products for Human Use, NSAIDs should be pharmacies to interview their customers within a given prescribed at the lowest effective dose and for the shortest time period, thereby obtaining a convenience sample. To period necessary for symptom control [14]. Moreover, obtain the 450 completed surveys, it was necessary to individual risk factors and the possibility of individual request the participation of 502 individuals. variability in response to NSAIDs must be considered by The questionnaire survey was developed using a sys- practitioners to improve patient management [15]. tematic approach, with the objectives of being concise and Some NSAIDs can be purchased without prescription, easy to understand. After pre-testing the survey in eight which allows patients to take responsibility for their therapy. individuals from the target population, changes were made Therefore, pharmacy professionals have a key role to play in in the text of some questions in order to improve under- counseling and promoting the appropriate selection of standing. The survey had two parts, and included closed NSAIDs, as they are the last link to patients before NSAID use. questions, with single or multiple choice responses, and The absence of data reflecting the prevalence and pat- one question with an open response. The first part inquired tern of use of NSAIDs in the Portuguese population, and about the sociodemographic characteristics of respondents, the attitudes and knowledge of healthcare providers, and the second asked about their health status and NSAID namely pharmacy professionals, towards the promotion of use, focusing primarily on issues relating to their pattern of their rational use, has prompted the undertaking of this consumption of NSAIDs. Respondents were asked if they study. A survey, using an investigator-administered ques- had taken NSAIDs in the last 6 months; only those par- tionnaire, was conducted in the central region of Portugal ticipants who had taken NSAIDs in the last 6 months in order to evaluate NSAID use by the adult population, to answered the remaining survey questions, which were characterize NSAIDs users, and to evaluate the role of related to the identification of used NSAIDs and factors community pharmacy professionals in NSAID use. associated with their consumption. The recall period of 6 months was chosen to obtain data regarding recent NSAID use. Individuals who had taken NSAIDs in the last Materials and methods 6 months indicated which NSAIDs they had used from a list of drugs (including brand-names), the signs and This was a cross-sectional study, with a questionnaire symptoms that motivated their use, and whether or not the survey developed by the authors being used as the data individual had a prescription for the NSAID, received collection instrument. Data collection took place in recommendations from pharmacy professionals when the NSAID was acquired, knew the adverse effects of the (61.4 %), female (67.6 %), urban zone inhabitants NSAID or had read the NSAID-related leaflets. (70.7 %) and involved in health study or labor activity Descriptive data analysis provided the sociodemo- (21.6 %). graphic characterization and description of health status According to the answers to the question